Prison ACCT process flaws
85 items
1 source
Insufficient multi-disciplinary input at Assessment, Care in Custody and Teamwork (ACCT) reviews, and over-reliance on the process.
Cross-Source Insight
Prison ACCT process flaws has been flagged across 1 independent accountability source:
85 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (85)
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Emmett Morrison
Concerns: HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Pending
Sundeep Ghuman
Concerns: Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Response: HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Overdue
Stuart Berry
Concerns: Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.
Response: HMPPS has developed interim upskilling sessions on self-harm and suicide risks for prison officers, and the Safety Support Skills training module is under national review. Four ligature-resistant cells were completed …
Response: HCRG is strengthening interfaces, retraining reception nurses, and has introduced a dedicated Early Days in Custody (EDiC) Nurse role to lead an action plan for improving care standards. They have …
Overdue
Aaron Taylor
Concerns: Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.
Response: HMPPS ensures all new officers receive training on suicide and self-harm prevention, including ACCT processes. HMP Garth has issued staff notices and a Governor's order in October and November 2025 …
Responded
Steven Hart
Concerns: Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Overdue
Brian Burrows
Concerns: Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Overdue
Azroy Dawes-Clarke
Concerns: The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.
Responded
Michael Pugh
Concerns: Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
Responded
Sarah Boyle
Concerns: The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.
Responded
Sean Higgins
Concerns: Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not understand how to properly complete support plan paperwork.
Responded
Kayleigh Melhuish
Concerns: HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a specific ligature point was identified in Residential Unit 3.
Overdue
Jonathon Lawlor
Concerns: Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Responded
Mark Beresford
Concerns: Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Responded
George Kyriacos Petrou
Concerns: Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Overdue
Sean Davies
Concerns: Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Overdue
Kevin McDonnell
Concerns: Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Responded
Matthew Braben
Concerns: Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
Overdue
Yasmin Adams
Concerns: Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.
Responded
Matthew Price
Concerns: Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.
Responded
Liam Turner
Concerns: It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Responded
Martin Willis
Concerns: The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.
Responded
Jack Zarrop
Concerns: Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.
Responded
Stewart Stanley
Concerns: Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.
Responded
Stuart Robinson
Concerns: Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Responded
Thomas Huntley
Concerns: Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.
Responded
Liridon Saliuka
Concerns: There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Responded
Khalid Abiaz
Concerns: A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Responded
Vijaykumar Gadhavi
Concerns: Systemic failures included a lack of learning from self-harm incidents, critical information flagging, poor property management, insufficient family involvement, and breaches of the Enhanced Care Policy.
Overdue
Saul Thomas
Concerns: A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.
Responded
Stephen Cope
Concerns: The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.
Overdue
Charlie Todd
Concerns: A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.
Responded
Colin Blackburn
Concerns: Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
Overdue
Geoffrey Hutton
Concerns: HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.
Responded
Corin Bonaparte
Concerns: HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.
Responded
Carl Newman
Concerns: Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.
Responded
Tomasz Nowasad
Concerns: There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.
Responded
Daniel Akam
Concerns: Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.
Overdue
Darren Williams
Concerns: ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.
Overdue
David Kirsch
Concerns: A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.
Responded
Harold Uzomechina
Concerns: Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.
Overdue
Amir Siman-Tov
Concerns: Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.
Overdue
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Overdue
Ryan Trimmer
Concerns: The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.
Responded
Daniel Davey
Concerns: Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Responded
Kelvin Speakman
Concerns: The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.
Responded
Nicky Reilly
Concerns: The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Responded
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Overdue
John Mayhew
Concerns: Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.
Overdue
Robert McLoughlin
Concerns: The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
Overdue
Mark Doyle
Concerns: Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Overdue
Mark Vagnoni
Concerns: Inadequate risk assessments and mental health input during "patrol state", unhelpful electronic record layouts, and missing transfer documentation for prisoners posed significant risks.
Overdue
Edwin O’Donnell
Concerns: Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Responded
Callum Smith
Concerns: There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.
Overdue
Dean Saunders
Concerns: Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Overdue
Margaret Atkinson
Concerns: Concerns were raised about the difficulty in describing and assessing risk from unusual prisoner behaviour, potentially leading to its normalisation and overlooking signs of increased risk.
Overdue
Matthew Russell
Concerns: Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Overdue
Roy Hoey
Concerns: Concerns arose from staff confusion regarding the interpretation and application of safer custody guidance, specifically when to open an ACCT plan, requiring clarification on mandatory assessment before initiation.
Responded
Haydn Burton
Concerns: Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.
Overdue
Liam Lambert
Concerns: ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.
Overdue
Warren Sampson
Concerns: Prison healthcare lacked consistent input in ACCT reviews and a follow-up process for missed screenings. Officers were also not adequately familiar with local directives.
Overdue
John Betteridge
Concerns: Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.
Overdue
Kevin Dermott
Concerns: Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and poor communication during transfers. These systemic failures and inadequate ACCT procedures contributed to the death.
Responded
Ian Brown
Concerns: Despite previous recommendations, HMP Woodhill has failed to rigorously implement strategies to reduce self-inflicted deaths, resulting in continued rises in suicide and self-harm due to inadequate ACCT case management.
Overdue
Sheldon Woodford
Concerns: Key safety documents (SASH) are not universally identifiable during reception, and officers receive insufficient training in ACCT processes for managing at-risk individuals.
Overdue
Matthew Sargent
Concerns: Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Responded
Steven May
Concerns: Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.
Overdue
Lee Rushton
Concerns: There is a lack of clear policy and training regarding how ACCT care plans and mandatory reviews should integrate with Cell Sharing Risk Assessments requiring single cell occupancy for prisoner protection.
Pending
Samuel Gale
Concerns: A prisoner's ACCT plan was closed without consulting crucial healthcare and management staff, suggesting a critical lapse in multi-disciplinary oversight for vulnerable individuals.
Responded
Liam Smith
Concerns: Mandatory ACCT procedures for self-harm risk were not followed, critical medical information was poorly disseminated within the prison, and limited healthcare interaction with high-risk drug users led to missed warning signs.
Overdue
Andrew Frere
Concerns: A national prison instruction for 24-hour doctor review is impracticable and ignored. Case managers also fail to read ongoing observations during ACCT reviews, risking missed critical information.
Pending
Carl Smith
Concerns: Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.
Overdue
Greg Revell
Concerns: Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.
Responded
Stuart Baumber
Concerns: Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.
Overdue
Alex Kelly
Concerns: A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Responded
Geraldine Kilborn
Concerns: There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.
Responded
Cherylin Norrell-Goldsmith
Concerns: Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.
Overdue
Seweryn Glowinski
Concerns: Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Overdue
Yohannes Kidane
Concerns: Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.
Responded
David O’Garro
Concerns: A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, created an unsafe cell allocation system.
Overdue
Matthew Purser
Concerns: A prison doctor lacked ACCT training, ACCT trigger event documentation was subjective and lacked detail for accurate assessment, and procedures for obtaining community mental health records were unclear.
Overdue
Ryan Clark
Concerns: Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Responded
Adrian Johnson
Concerns: Systemic failures in prison healthcare led to inadequate screening and management of tobacco withdrawal, significantly increasing the prisoner's vulnerability and anxiety. This was exacerbated by poor communication and inconsistent ACCT reviews.
Response: NOMS and NHS England agree to give further consideration to identifying tobacco dependence and withdrawal during prisoner screenings. They will reinforce policy regarding segregation unit placement for prisoners subject to …
Overdue
Michael James Meyler
Concerns: Prison systems failed to adequately circulate self-harm/suicide risk information to relevant staff and attach it to ACCT documents, leading to uninformed decisions and a lack of accountability for information review.
Pending
Reggie John
Concerns: Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Response: Following the inquest, the Lead for Offender Health set out clear expectations to all healthcare staff at HMP Hewell regarding ACCT documents for arriving prisoners, ensuring they are available to …
Response: NOMS reports that HMP Bristol has introduced a system to contact receiving establishments via email and phone for prisoners on open ACCTs, and escort contractors are also informed. HMP Hewell …
Overdue